The University at Albany School of Public Health proposes to investigate the impact of managed care on outcomes for seriously ill patients under the new competitive hospital reimbursement system in New York State. With the environment of rising service utilization and the reduction in hospital reimbursements for ICU patients, there are a number of issues that should be addressed or health care costs will become increasingly unmanageable. The analysis will focus on costs and outcomes of services received among patients with prolonged mechanical ventilation discharged under DRG 475 and DRG 483 due to their large impact on health care expenditures. The goals of this study are: to determine whether the improved survival rates among managed care organization patients are due to self-selection or the elimination of ineffective care in the inpatient setting and to establish a benchmark to determine which hospital practices are associated with the best outcomes for these patients. This project has the unique opportunity to analyze outcomes for managed care and traditionally covered patients before and after the institution of competitive reimbursements using detailed medical record and long-term survival data during 1995-1997 from a high-volume medical center. This extensive secondary data on patient risk factors, treatment protocols and patterns, and discharge planning will complement and validate the general analysis of managed care impacts using public-use administrative discharge abstracts for these patients among all general acute care facilities in New York during this period. An extension of the model by Angus will be used to test hypotheses in both the statewide and pilot study components concerning the impacts of managed care and reimbursement structures on survival rates, lengths of stay in the ICU and hospital, discharge patterns for survivors, and costs per survivor. Ordinary least square and identity-linked geometric regression models will be developed to predict outcomes for the hypotheses as appropriate. This small project is in preparation for a larger effort that will use patient billing and medical record data from a representative sample of hospitals in New York to perform cost-effectiveness analyses of acute and post-acute care for these patients to address cost-shifting issues across venues of care. The findings from this study will inform public and private policy concerning the impact of managed care, reimbursement regimes, and hospital practice patterns on economic and health outcomes across acute and post-acute settings for critically ill patients.